Supporting the Vision and Inspiration for Socially Engaged Buddhism Throughout the World

Please fill out the form below and push the submit button (at the bottom of the form), the return key,
or the enter key to send it to us. The tab key will take you from field to field.

When you click on the "Submit Button" you will be forwarded back to the Bearing Witness Training Program page.

For more information, please contact Ginni Stern: ginnni@zenpeacemakers.com, or by Phone: 802-734-6223


First Name      Last Name  

Name you like to be called  



Address  

Address2  

City    State   or Province  

Country   Zip Code  


Home Telephone            Office Telephone                               Cellular Telephone
   

E-Mail Address

How did you hear about this training program?  

Your birthdate.  


English is the primary language used in this training although, in some trainings, we will have translation. In order to assist staff please indicate your language abilities. Also, if you are willing/able to assist others with translations in which language?

Primary Language  

Fluency in English  

In order to assist those attending with varying fluency in English, please choose the languages below that you are willing to assist others with translations. Thank you in assisting us in helping others.

Fluency in German     Fluency in Polish     Fluency in Spanish    

Fluency in Italian     Fluency in Arabic     Fluency in Hebrew    

Fluency in Dutch     Fluency in Flemish     Fluency in French    

Fluency in (Input other language you have fluency in)  

Participant's Gender  



There are some single rooms available. If you are attending the retreat as a couple, please list your roommate below and select "yes" on the couple's button.

Desired Roommate's Name


We are a couple  


If you leave the Desired Roomate blank, you will be assigned roommates of your own gender.

Vegetarian  

Other medical dietary requirements:



Other comments, special needs or medical conditions you'd like the training staff to know about:

Emergency Information

In case of emergency whom should we contact? Please note someone NOT at the retreat with you.

Emergency Contact Name:  

Primary Language of Contact       Contact's Fluency in English  

Relation to you:   Country Emergency Contact lives in:  

Emergency Contact Phone #'s:
Mobile  Home  Office  

Emergency Contact Email address: